Part 67

Sometimes the anterior tibial artery passes undivided through the tarsus, gives off the internal deep plantar metatarsal, and is continued as a very large internal superficial plantar metatarsal along the deep flexor tendon, thus resembling the arrangement in the fore limb.

In a few cases the perforating tarsal is a large vessel, directly continuing the anterior tibial, and is continued by a large internal deep plantar metatarsal. The great metatarsal is then small. Other variations are common.

THE GREAT METATARSAL ARTERY

This artery (A. metatarsea dorsalis lateralis) is the direct continuation of the anterior tibial. It passes downward and outward under the extensor brevis and the tendon of the lateral extensor, at first on the joint capsule and then in the oblique vascular groove on the upper part of the large metatarsal bone. It then descends in the groove formed by the apposition of the large and external small metatarsals, inclines inward between the two, and divides on the lower part of the posterior face of the large metatarsal bone into the internal and external digital arteries. It is not usually accompanied by a vein. Beyond this the arterial arrangement is the same as in the thoracic limb.

THE VEINS[168]

PULMONARY VEINS

The terminal =pulmonary veins= (Vv. pulmonales), usually seven or eight in number, return the aërated blood from the lungs and open into the left atrium of the heart. They are destitute of valves. Their tributaries arise in the capillary plexuses in the lobules of the lungs, and unite to form larger and larger trunks which accompany the branches of the bronchi and pulmonary arteries. A very large vein is formed by the union at an acute angle of a trunk from each lung, where the latter are adherent to each other.

SYSTEMIC VEINS

THE VEINS OF THE HEART (Figs. 426, 427)

The =coronary sinus= (Sinus coronarius) is a very short bulbous trunk which receives most of the blood from the wall of the heart. It is situated just below the termination of the posterior vena cava and is covered in part by a thin layer of ventricular muscle-fibers. It opens into the right atrium just below the posterior vena cava. It is formed by the union of two tributaries. The =great cardiac= or =left coronary vein= (V. cordis magna) begins at the left side of the apex of the heart, ascends in the left longitudinal groove and turns backward in the coronary groove, in which it winds around the posterior border of the heart to the right side and joins the coronary sinus. The =middle cardiac= or =right coronary vein= (V. cordis media) begins on the right side of the apex, ascends in the right longitudinal groove and joins the coronary sinus, or opens separately into the atrium just in front of the orifice of the left vein, so that a common trunk (coronary sinus) does not then exist.

The =small cardiac veins= (Vv. cordis minores), three to five in number, are small vessels which return some blood from the right ventricle and atrium; they open into the latter near the coronary groove in spaces between the musculi pectinati.

THE ANTERIOR VENA CAVA (Fig. 429)

The =anterior vena cava= (V. cava cranialis) returns to the heart the blood from the head, neck, thoracic limbs, and the greater part of the thoracic wall. It is formed at the ventral part of the thoracic inlet by the confluence of the two jugular and two brachial veins. Its origin is attached to the first pair of ribs. It passes backward in the anterior mediastinum, at first median and ventral to the common carotid trunk, then deviates to the right of the anterior aorta, and opens into the right atrium opposite to the third rib. The demarcation between vein and atrium is not very distinct. It contains no valves except at the mouths of its radicles. Its length is about five to six inches (ca. 12 to 15 cm.) and its caliber about two inches (ca. 5 cm.) in a subject of medium size. Its right face is crossed by the right phrenic nerve, and on the left it is related to the anterior aorta and brachiocephalic artery. It receives, in addition to small pericardial and mediastinal veins, the following tributaries:

1. The =internal thoracic vein= (V. thoracica interna) is a satellite of the artery of that name. It opens into the anterior vena cava at the first rib.

2. The =vertebral vein= (V. vertebralis) corresponds to the homonymous artery. On the right side it terminates either in front of the deep cervical vein or by a short common trunk with it. On the left side it almost always unites with the deep cervical and vertebral vein to form a common trunk.

3. The =deep= or =superior cervical vein= (V. cervicalis profunda) corresponds to the artery. On the right side it leaves the artery at the first intercostal space, crosses the right face of the trachea and opens into the vena cava; it may form a common trunk with the dorsal or vertebral. On the left side there is nearly always a common trunk for all three.

4. The =dorsal vein= (V. costo-cervicalis) corresponds to the artery. On the right side it leaves the artery on entering the thorax, crosses the right face of the trachea, and opens into the vena cava in front of the deep cervical or by a common trunk with it. On the left side it almost always joins the deep cervical and vertebral to form a short common trunk which crosses the left face of the intrathoracic part of the brachial artery opposite the second rib and opens into the anterior vena cava.

THE VENA AZYGOS

The =vena azygos= (Fig. 429) is an unpaired vessel which arises at the level of the first lumbar vertebra by radicles coming from the psoas and the crura of the diaphragm; it is connected with the first lumbar vein. It passes forward along the right side of the bodies of the thoracic vertebræ, in contact usually with the thoracic duct, which separates the vein from the aorta. At the seventh vertebra it leaves the spine, curves downward and forward over the right side of the thoracic duct, trachea, and œsophagus, and opens into the right atrium opposite the third intercostal space. Its tributaries are:

1. The last fourteen =intercostal veins= (Vv. intercostales) of the right side. On the left side the last four to seven intercostal veins usually empty into the =vena hemiazygos=. This vessel runs on the left side of the aorta from the fourteenth to the eleventh thoracic vertebra, passes between the aorta and the spine, and joins the vena azygos. In its absence its tributaries join the vena azygos.

2. The =œsophageal vein= (V. œsophagea), satellite of the œsophageal artery, joins the vena azygos as it inclines downward.

3. The =bronchial vein= (Vena bronchialis) unites with the preceding to form a short common trunk (Ellenberger-Baum), or empties into the great coronary vein (Chauveau).[169]

VEINS OF THE HEAD AND NECK

JUGULAR VEINS

The =jugular veins= (Vv. jugulares), right and left (Fig. 431), arise behind the posterior border of the lower jaw about two and a half inches (ca. 6 to 7 cm.) below the temporo-maxillary articulation by the union of the superficial temporal and internal maxillary veins. Each passes downward and backward, at first embedded more or less in the parotid gland, and continues in the jugular furrow to the thoracic inlet, where it unites with its fellow and the two brachial veins to form the anterior vena cava. In the neck it is covered by the skin, fascia, and panniculus, and is superficial to the carotid artery, from which it is separated in the anterior two-thirds of the region by the omo-hyoideus muscle.[170] It contains valves at the mouths of its tributaries and has several pairs of semilunar valves variably disposed along its course. Its tributaries are as follows:

1. The =internal maxillary vein= (V. maxillaris interna) is larger than the external maxillary. It may be considered to begin as the continuation backward of the buccinator vein where the vessel crosses the alveolar border of the mandible (about two inches (ca. 5 cm.) behind the last molar tooth). It runs backward on the inner surface of the ramus below the external pterygoid and covered by the internal pterygoid muscle for a distance of about three inches (ca. 7 to 8 cm.), then inclines a little downward and runs ventral to the artery for about an inch (ca. 2 to 3 cm.). It crosses the external face of the artery at the posterior border of the jaw, and is joined by the superficial temporal vein to form the jugular. Its principal radicles are:

(1) The =dorsal lingual vein= (V. dorsalis linguæ), which is a satellite of the lingual nerve.

(2) The =inferior alveolar= or =dental vein= (V. alveolaris mandibulæ), a satellite of the corresponding artery. It often unites with the preceding.

(3) =Pterygoid veins= (Rami pterygoidei).

(4) The =deep temporal vein= (V. temporalis profunda) is a large vessel which receives tributaries from the temporalis muscle and emissaries from the parieto-temporal canal. It is connected with the anterior cerebral vein and usually with the meningeal veins by its frontal branch. The latter drains chiefly the lacrimal gland and passes behind the supraorbital process.

2. The =superficial temporal vein= (V. temporalis superficialis) is a satellite of the corresponding artery. It is formed by the confluence of the =anterior auricular= and =transverse facial veins=. The former receives the =superior cerebral vein= (V. cerebralis dorsalis), which is the emissary of the transverse sinus of the dura mater; it emerges from the parieto-temporal canal behind the postglenoid process. The =transverse facial vein= (V. transversa faciei) runs at first above the artery of like name, then plunges deeply into the masseter and unites in front with the facial vein. It is connected with the vena reflexa.

3. The =inferior masseteric= or =maxillo-muscular vein= (V. masseterica) joins the jugular at the upper border of the sterno-cephalicus tendon. It is a short trunk formed by the confluence at the posterior border of the jaw of masseteric and pterygoid veins. The former is usually connected by a large branch with the buccinator vein.

4. The =great auricular vein= (V. auricularis magna) is a satellite of the posterior auricular artery above, but joins the jugular a variable distance below and behind the point of origin of the artery.

5. The =inferior cerebral vein= (V. cerebralis ventralis) is an emissary of the cavernous sinus of the dura. It is a satellite of the internal carotid artery, receives the =condyloid vein=, and joins the jugular near the occipital vein or by a common trunk with it.

6. The =occipital vein= (V. occipitalis) arises in the fossa atlantis by the union of muscular and cerebrospinal branches. The former comes from the muscles of the poll and passes through the foramen transversarium. The latter is connected with the occipital sinus of the dura mater and emerges from the spinal canal by the intervertebral foramen.

7. The =external maxillary= or =facial vein= (V. maxillaris externa) arises by radicles which correspond in general to the branches of the artery of like name. It passes down over the cheek along the anterior border of the masseter muscle behind the artery, crossing over the parotid duct, which lies behind the vein lower down. Thus on the ramus and as they turn around its lower border the artery is in front, the vein in the middle, and the duct posterior. In the submaxillary space the vein is ventral to the artery for some distance, then parts company with the artery, runs straight backward along the lower border of the parotid gland, and opens into the jugular vein at the posterior angle of the gland.[171] The chief differences in the tributaries of the vein as compared with the branches of the corresponding artery are as follows:

The =labial veins= (Vv. labiales) form a plexus in the submucous tissue of the cheek from which two veins emerge. The upper one passes back and joins the buccinator vein. The lower one (V. labialis communis) joins the external maxillary vein.

Three veins connect with the external maxillary at the anterior border of the masseter.

The upper one is the =transverse facial=, which unites close to the end of the facial crest.

A little lower is the large valveless =vena reflexa= or =alveolar vein=. This passes back under the upper part of the masseter on the maxilla, turns around the tuber maxillare, perforates the periorbita, and joins the ophthalmic vein. It is relatively small at each end, but presents one or two large fusiform dilatations. It receives the following tributaries: (_a_) The =palatine vein= (V. palatina major), which separates from the palatine artery at the anterior palatine foramen and passes in the groove between the tuber maxillare and the palate bone. The palatine veins form a very rich plexus of valveless vessels in the submucosa of the hard palate, which consists of several layers anteriorly. (_b_) The =sphenopalatine vein= (V. sphenopalatina) forms a rich plexus of valveless vessels on the turbinal bones and the septum nasi. It is usually joined by the =infraorbital vein= (V. infraorbitalis) to form a short common trunk.

The venous plexuses are remarkably developed in certain parts of the nasal mucosa. On the septum a little below its middle and on the turbinals the veins are in several layers. The olfactory region does not share in this arrangement and the veins here are small and join the ethmoidal vein.

(_c_) The =ophthalmic vein= (V. ophthalmica) is a short trunk, connected in front with the vena reflexa and behind with the cavernous sinus through the foramen lacerum orbitale. It receives veins which correspond to the arterial branches.

The =buccinator vein= (V. buccinatoria) extends backward from the external maxillary along the lower border of the depressor labii inferioris and buccinator under cover of the masseter, passes between the ramus of the mandible and the tuber maxillare and is continued as the internal maxillary vein. It has a large fusiform dilatation and is valveless. It receives a large common labial vein from the labial plexus, and is usually connected with the masseteric vein.

The =lingual vein= (V. lingualis) is not a satellite of the artery. It is formed at the side of the lingual process of the hyoid bone by the confluence of several veins which come from the substance of the tongue. One or two considerable vessels run partly in the substance of the hyo-glossus, and another in the genio-hyoideus. The vein is at first covered by the mylo-hyoideus, perforates that muscle, runs back along the omo-hyoideus in relation to the submaxillary lymph glands, and joins the external maxillary near the posterior border of the jaw. Near its termination it receives the =sublingual vein=, or the latter may open into the external maxillary directly.

8. The =thyroid vein= (V. thyreoidea) is a large vessel which joins the jugular near the external maxillary vein. It receives anterior thyroid, laryngeal, and pharyngeal radicles, and sometimes a posterior thyroid vein.

9. =Muscular=, =tracheal=, and =œsophageal= veins.

10. The =cephalic vein= (Vena cephalica) enters the jugular near its termination. It will be described with the veins of the thoracic limb.

11. The =inferior cervical vein= (V. cervicalis ascendens) accompanies the artery. It may open into the brachial vein.

THE SINUSES OF THE DURA MATER

These (Sinus duræ matris) are blood-spaces between the meningeal and periosteal layers of the dura mater and are lined with endothelium. In many places the lumen is crossed by fibrous strands. They receive the veins of the brain, communicate with the meningeal and diploic veins, and with veins outside of the cranium; their connections with the latter are by means of small =emissary veins= (Emissaria). They convey the blood directly or indirectly to the jugular veins. Some are paired, others unpaired. They may be divided into dorsal and basilar systems. The =dorsal system= comprises the following:

The =superior longitudinal= or =sagittal sinus= (S. sagittalis superior) is situated in the upper border of the falx cerebri along the internal sagittal crest. It begins at the crista galli and ends at the tentorium osseum by dividing into two transverse sinuses. It receives the superior cerebral veins. Along each side are small pouches (Lacunæ laterales) into which the veins open. The lumen of the sinus is traversed by fibrous bands and is partially divided by a longitudinal septum.

The =transverse sinuses= (S. transversi), right and left, pass outward in the transverse grooves of the parietal bones, enter the parieto-temporal canals, and are continued by the superior cerebral veins to the superficial temporal veins. The two sinuses are connected by the sinus communicans.

The =inferior longitudinal= or =sagittal sinus= (S. sagittalis inferior) runs backward on the upper surface of the corpus callosum along the concave edge of the falx cerebri and joins the great cerebral vein (of Galen) to form the straight sinus.

The =straight sinus= (S. rectus) passes upward and backward between the cerebral hemispheres and in the tentorium cerebelli and joins the superior sagittal sinus. The point of meeting is the confluence of the sinuses (Confluens sinuum).

The =occipital sinuses= (S. occipitales) lie on either side of the vermis cerebelli. They empty anteriorly into the sinus communicans and communicate behind with the spinal veins.

The =superior petrosal sinuses= (S. petrosi superiores) pass in the tentorium cerebelli to end in the transverse sinuses.

The =basilar system= consists of the following:

The =cavernous sinuses= (S. cavernosi) lie in the inner grooves of the root of the temporal wings of the sphenoid bone at either side of the sella turcica. The two are connected by a wide traverse branch (Sinus intercavernosus) behind and below the posterior part of the pituitary body. Each is continuous in front with the ophthalmic vein and below with the inferior petrosal sinus. The third, sixth, and the ophthalmic and maxillary divisions of the fifth nerve lie along the outer wall of the sinus. The internal carotid artery traverses the sinus and is connected with its fellow by a transverse branch which lies in the corresponding part of the sinus. An oval opening in the floor communicates with the inferior petrosal sinus and transmits the internal carotid artery.

The sinus is not subdivided by strands of fibrous tissue as in man, but a few delicate bands attach the artery to its wall.